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Being present

Mindfulness and nursing practice

Bernstein, Sandra MSN, RN, APRN-CS, LMFT

doi: 10.1097/01.NURSE.0000558105.96903.af
Department: NEW BEHAVIORAL HEALTH
Free

Sandra Bernstein is a practicing psychotherapist in Lansdale, Pa., and Doylestown, Pa.

The author has disclosed no financial relationships related to this article.

BEFORE YOU read this, take a moment to check in with yourself. What thoughts were foremost in your mind before you began to read? Were you rehashing something from the past or thinking about the future? Notice what physical sensations are present in your body. When you stop to pay attention, do you become aware of areas of tension or discomfort? What emotions are present now? Having become aware of thought, sensation, and emotion, focus now on your breathing. Follow the flow of air as you breathe in and breathe out three times. When you notice your mind has wandered from the breath, gently and without judgment return your attention to your breath for a few more cycles. When you are ready, widen the field of your attention to once more bring awareness to thought, body sensations, and emotion. What, if anything, has shifted in these moments of paying attention?

Nursing has many stressors that include working long hours; coping with the pain, loss, and suffering of patients and families; dealing with staffing issues and the increasing acuity and complexity of patient care; and navigating institutional financial constraints.1 Compassion fatigue and burnout are common, and balancing career and family presents additional challenges and stress. This article discusses how mindfulness-based practices, such as the exercises described above, can help nurses more effectively manage their stress and improve their resiliency.

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What is mindfulness?

One definition of mindfulness is “awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally.”2 When being mindful, you are aware of the flow of moment-to-moment experience (your thoughts, physical sensations, and emotions) without getting caught up in automatic reactions or positive or negative judgments. It emphasizes accepting things as they are in the present moment and meeting all experiences with openness, curiosity, and compassion.

Jon Kabat-Zinn describes the attitudes basic to mindfulness practice as follows:

  • Nonjudging: observing experience without getting caught up in thoughts and opinions, likes, and dislikes.
  • Patience: accepting that things unfold in their own time.
  • Beginner's mind: being willing to see everything as if for the first time.
  • Trust: trusting in yourself and your own basic wisdom.
  • Nonstriving: holding experience in awareness without doing anything with it.
  • Acceptance: seeing things as they are, clearly, not as we wish they were.
  • Letting go: letting things be, without trying to hold or to reject parts of our experience.3

Cultivating these attitudes and an ongoing mindfulness meditation practice (“practice” in the sense of a regular action or habit) requires commitment, self-discipline, and intentionality.3 Mindfulness differs from relaxation techniques in that it is not learned and used episodically; its true impact on one's life emerges from its exercise over time. Rather than seek to bring the person to a particular state, mindfulness practice supports an experience that is characterized by curiosity, openness, and acceptance.4

We are on “automatic pilot” much of the time. We think in either/or and black/white terms. We get so lost in our automatic thoughts and emotions about an event that we do not see the experience in the moment as it really is.3 We may not be in touch with bodily sensations such as fatigue, hunger, anger, or pain. Mindfulness trains us to be more discerning and distinguish our actual experiences from the interpretations and judgments we make of them. It trains us to meet difficult and unpleasant situations with acceptance and to be more aware of the flow of thoughts and feelings that we initially experience.5 By doing so, we can create openings for other responses to manage stress and find different coping strategies. We “fall awake” and become present in our own lives.

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Types of mindfulness

Mindfulness can be experienced as formal meditation practice or as everyday mindfulness, also called informal practice. Formal meditation practice is the training lab for developing greater everyday mindfulness. The focus is on your own experience: As you direct attention to a particular event (for instance, breath-based concentration meditation), you become aware of the flow of thoughts, sensations, and emotions that emerge, hijacking your attention. (See Types of formal meditation practice.) Another example is compassion practice, also known as metta, which involves repeating a series of phrases to direct loving-kindness and ease to oneself and others. (See A closer look at metta.)

Informal meditation practice involves bringing attention to everyday life itself—from simple activities like showering and washing dishes to more complex things such as noticing hunger and taking time to eat, or recognizing tension or pain and taking steps to relieve it. For example, when taking a shower, know you are taking a shower. Notice the water, the scent of the soap, and the feel of your bath sponge on your skin. Bring awareness to your breath as you wait for an elevator, noticing what emotions, thoughts, and physical sensations are present in the moment. Allow yourself to take some deep relaxation breaths and notice what, if anything, shifts for you. You may find that this process of checking in with yourself helps you identify stress and concerns early, before they escalate.

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Mindfulness for nurses

Imagine you are gowned and gloved for a sterile procedure, and your cheek starts to itch. You want to scratch; trying to ignore it only makes the urge stronger. What if, instead, you simply notice and accept “itch on face” and move your attention back to the procedure without digressing into a commentary on the itch? The itch can become just an itch, whose intensity will most likely wax and wane no matter what you do about it.

Mindfulness practices have been found beneficial for nurses. One approach is mindfulness-based stress reduction (MSBR). Originally developed in 1979 by Kabat-Zinn at the University of Massachusetts School of Medicine, the traditional MBSR program is administered over 8 weeks, with one additional all-day retreat. The program has been found to increase self-compassion, serenity, and empathetic concern as well as decrease burnout and self-reported distress in nurses.6

A 2005 randomized controlled pilot study of an MBSR program for nurses in a medical center found that MBSR reduced burnout and emotional exhaustion and that these changes were maintained at a 3-month follow-up.7 Professional caregivers who completed an MBSR program have shown increased abilities to see another's perspective and identify and accept their own emotions.8 A positive relationship between empathy and decreased burnout has also been reported.9

Meditation strengthens the neural pathways for compassion and empathy, and compassion has been found to mute the distress that leads to burnout. Cultivation of loving concern for others also energizes brain circuits for happiness. Responsiveness to compassion practices has been found to occur quickly—these brain circuits are apparently ripe for attention.10 This finding makes sense: Being biologically/neurologically primed to care about others would seem important to our survival as a species. For nurses, this, combined with the improved ability to pay attention and the emotional regulation that meditation facilitates, may lead to safer practice and better self-care. This can translate into improved job satisfaction and less burnout.

Healthcare employers and nursing organizations can make MBSR programs available either by offering in-house programs or financially supporting program attendance. Ongoing support for practice, such as facilitated meditation groups, periodic refreshers, and even mini-retreats, can also be provided. In addition to the personal and professional benefits of developing a mindfulness practice, nurses are well suited to become teachers of mindfulness and bring it to those they care for. The Center for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts maintains an international directory of certified mindfulness teachers and programs, which can be found online at www.umassmed.edu/cfm/mindfulness-based-programs/mbsr-courses/find-an-mbsr-program.

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MBIs: A therapeutic option

The use of mindfulness-based interventions (MBIs) in healthcare has grown dramatically, and evidence supports their efficacy in helping manage stress and enhance well-being in both healthy and chronically ill populations. The American Mindfulness Research Association (https://goamra.org) issues a monthly update of mindfulness research, interventions, and trials.

Beyond MBSR programs, MBIs have been studied as therapy for behavioral health disorders such as depression, anxiety, and posttraumatic stress disorder. They are being studied for therapeutic value in pain management, hypertension, irritable bowel syndrome, ulcerative colitis, binge eating and weight management, cancer, substance abuse, childbirth, and smoking cessation.11 Some evidence suggests that mindfulness meditation may also have salutary effects on immune function and inflammatory response.11-13

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Research limitations

However, some of the excitement around mindfulness is anecdotal and research findings are often mixed or inconclusive. Among the problems identified in much of the current research are nonrandomized designs, small sample sizes, reliance on self-report measures, varying frequency and duration of meditation, the wide variety of practices and outcome measures used, and lack of long-term follow-up. The strongest evidence supports MBSR for stress reduction and enhanced well-being, but research has yet to definitively reveal the mechanisms behind these benefits.

These research limitations are being addressed as the science of mindfulness has a place in more major research centers. For example, the University of Massachusetts announced the creation of the Division of Mindfulness, the first of its kind, in 2018. This marks a major step in the academic area and a move away from the traditional mind-body split of medical care to an understanding of the “seamless interconnectedness of brain, mind, body, experience and well-being.”5

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Seeing the person, not the patient

At the end of the day, as you walk to yet another patient's room, take a moment to check in with yourself. What are you thinking about? What physical sensations and emotions are present? Drawing on mindfulness practice, note and accept whatever is present, and bring your attention to rest in your breathing, following the flow of several breaths and centering yourself. Perhaps then you can see the person in the room, not just the patient, and engage your compassionate response to their needs. Is this being present with another the heart of nursing practice?

Mindfulness practice helps nurses to be more fully present with their patients and themselves. The ability to pay attention to what is happening “right now,” in this room with this patient, and not be distracted by other demands and concerns, creates space to use your wisdom and knowledge effectively and with care for the dignity of each patient. Being more present to your own experience and habitual responses increases your ability to manage stress and enhances decision-making, well-being, and self-efficacy.

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Types of formal meditation practice3

Breath-based concentration meditation: attention is focused on the breath and sensations of breathing for a set period of time. The most basic instruction is to pay attention to each breath and, when the mind wanders, come back to the breath without judgment. This can be practiced sitting, lying down, or standing. Using breathing as a focus has built-in advantages: It is always available, it is under conscious as well as automatic control, and it serves as an anchor to which you can return when you realize you have been pulled away.

The body scan: a practice in which attention is systematically directed through the entire body, usually done while lying on your back.

Choiceless awareness: being present with and accepting of whatever emerges in awareness without holding on to anything; simply witnessing in stillness.

Walking meditation: a practice in which you walk knowing you are walking, are paying attention to the physical sensations of movement, and are coming back to sensations if the mind wanders. It is often practiced as a slow walking back and forth.

Yoga: a practice in which you are slowly moving through a series of gentle stretching, strengthening, and balancing exercises (poses or asanas) with awareness of breathing and sensations that arise.

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A closer look at metta3

Metta, or loving-kindness meditation, consciously invites feelings of love and kindness to us and others to arise, be held in awareness, and be felt in the body while repeating a series of simple phrases. Some people like to begin by offering these phrases to themselves, then going outward to include other people they know or even strangers. Others find it easier to first offer them to a loved being (such as a child, partner, or pet) before offering them to themselves. While saying these phrases we can visualize the other being in our mind's eye or just hold the feeling of them in our heart. We can then choose to extend the offering to include others we know (alive or dead), to those we do not know or even those with whom we have difficulties, and to all people who suffer.

The following phrases may be used, or you may choose to make up some that resonate for you. Sometimes, it may be appropriate to add “to the extent possible” to make these phrases fit a particularly difficult situation.

  • May I be free from inner and outer harm.
  • May I be happy.
  • May I be healthy.
  • May I live with ease.
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REFERENCES

1. Botha E, Gwin T, Purpora C. The effectiveness of mindfulness based programs in reducing stress experienced by nurses in adult hospital settings: a systematic review of quantitative evidence protocol. JBI Database System Rev Implement Rep. 2015;13(10):21–29.
2. Kabat-Zinn J. Meditation Is Not What You Think: Mindfulness and Why It Is So Important. New York, NY: Hachette Books; 2018.
3. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. Rev. ed. New York, NY: Bantam Books; 2013.
4. Siegel DJ. Pocket Guide to Interpersonal Neurobiology: An Integrative Handbook of the Mind. 1st ed. New York, NY: WW Norton & Company; 2012.
5. Kabat-Zinn J. A major turning point for mindfulness in health care. 2018. Mindful. http://www.mindful.org/umass-medical-school-creates-first-division-mindfulness.
6. Penque S. Mindfulness-based stress reduction effects on registered nursing. University of Minnesota Digital Conservancy. 2009. http://hdl.handle.net/11299/58728.
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8. Lamothe M, McDuff P, Pastore YD, Duval M, Sultan S. Developing professional caregivers' empathy and emotional competencies through mindfulness-based stress reduction (MBSR): results of two proof-of-concept studies. BMJ Open. 2018;8(1):e018421.
9. Hunt PA, Denieffe S, Gooney M. Burnout and its relationship to empathy in nursing: a review of the literature. J Res Nurs. 2017;22(1-2):7–22.
10. Goleman D, Davidson R. Altered Traits: Science Reveals How Meditation Changes Your Mind, Brain, and Body. New York, NY: Avery Publishing; 2017.
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